Test Bank Questions

Question 1

The nurse is discussing risk factor modification for a client who has a 4-cm abdominal aortic aneurysm. The nurse should focus client teaching on which of the following risk factors?

1. Male gender
2. Marfan syndrome
3. Abdominal trauma history
4. Uncontrolled hypertension

Answer 1

4.

Question 2

The nurse is obtaining a health history from a client who has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. Which of the following symptoms should the nurse expect to assess in the client?

1. Back or lumbar pain
2. Difficulty swallowing
3. Abdominal tenderness
4. Changes in bowel habits

Answer 2

2.

Question 3

Several hours after an open surgical repair of an abdominal aortic aneurysm, the client develops a urinary output of 20 mL/hour for 2 hours. Which of the following prescriptions should the nurse anticipate?

1. An additional antibiotic
2. White blood cell (WBC) count
3. Decrease in IV infusion rate
4. Blood urea nitrogen (BUN) level

Answer 3

4.

Question 4

A client in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which of the following medication categories should the nurse plan to include when providing client teaching about PAD management?

1. Statins
2. Vitamins
3. Thrombolytics
4. Anticoagulants

Answer 4

1.

Question 5

The nurse is caring for a client with chronic atrial fibrillation who develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions should the nurse implement first?

1. Elevate the left leg on a pillow.
2. Apply an elastic wrap to the leg.
3. Assist the client in gently exercising the leg.
4. Notify the health care provider.

Answer 5

4.

Question 6

A client at the clinic says, “I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though.” Which of the following actions should the nurse implement?

1. Attempt to palpate the dorsalis pedis and posterior tibial pulses.
2. Check for the presence of tortuous veins bilaterally on the legs.
3. Ask about any skin colour changes that occur in response to cold.
4. Assess for unilateral swelling, redness, and tenderness of either leg

Answer 6

1.

Question 7

The nurse is assessing a client who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe. Which of the following findings should the nurse expect?

1. A positive Homans’ sign
2. Swollen, dry, scaly ankles
3. Prolonged capillary refill in all the toes
4. A large amount of drainage from the ulcer

Answer 7

3.

Question 8

The nurse is providing teaching to a client with critical limb ischemia. Which of the following client statements indicate further teaching is required?

1. “I will have to buy some loose clothing that does not bind across my legs or waist.”
2. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.”
3. “I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily.”
4. “I will change my position every hour and avoid long periods of sitting with my legs down.”

Answer 8

2.

Question 9

The nurse notes bruising and discoloration of the right leg of a client that has just arrived in the recovery unit from having vein ligation surgery. Which of the following interventions is priority?

1. Place the client in the Trendelenburg position.
2. Contact the health care provider.
3. Elevate the bed at the knee and put pillows under the feet.
4. Elevate the legs 15 degrees to limit edema.

Answer 9

4.

Question 10

The health care provider prescribes an infusion of argatroban and daily partial thromboplastin time (PTT) testing for a client with venous thrombo-embolism (VTE). Which of the following actions should the nurse include in the plan of care?

1. Avoid giving any IM medications to prevent localized bleeding.
2. Discontinue the infusion for PTT values greater than 50 seconds.
3. Monitor posterior tibial and dorsalis pedis pulses with the Doppler.
4. Have vitamin K available in case reversal of the argatroban is needed.

Answer 10

1.

Question 11

A client with a venous thrombo-embolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are necessary. Which of the following responses by the nurse is accurate?

1. “Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.”
2. “Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from occurring.”
3. “The enoxaparin will work immediately, but the warfarin takes several days to have an effect on coagulation”
4. “Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.”

Answer 11

3.

Question 12

The nurse has initiated discharge teaching for a client who is to be maintained on warfarin following hospitalization for venous thrombo-embolism (VTE). Which of the following client statements indicates that additional teaching is required?

1. “I should reduce the amount of green, leafy vegetables that I eat.”
2. “I should wear a Medic Alert bracelet stating that I take warfarin.”
3. “I will need to have blood tests routinely to monitor the effects of the warfarin.”

Answer 12

1.

Question 13

The nurse is caring for a client who had a sclerotherapy for treatment of superficial varicose veins and is a service-counter worker. Which of the following information should the nurse include when providing discharge teaching to the client?

1. Sitting at the work counter, rather than standing, is recommended.
2. Compression stockings should be applied before getting out of bed.
3. Exercises such as walking or jogging cause recurrence of varicosities.
4. Taking one Aspirin daily will help prevent clotting around venous valves.

Answer 13

2.

Question 14

The nurse is providing teaching to a client with chronic venous insufficiency who has a venous ulcer on the right lower leg. Which of the following topics should the nurse include in the teaching plan?

1. Adequate carbohydrate intake
2. Prophylactic antibiotic therapy
3. Application of compression to the leg
4. Methods of keeping the wound area dry

Answer 14

3.

Question 15

A client is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of the following client statements is most consistent with this diagnosis?

1. “I can’t get my shoes on at the end of the day.”
2. “I can never seem to get my feet warm enough.”
3. “I wake up during the night because my legs hurt.”
4. “I have burning leg pains after I walk three blocks.”

Answer 15

1.

Question 16

Which of the following nursing actions should be included in the plan of care for a client who has had endovascular repair of an abdominal aortic aneurysm?

1. Record hourly chest tube drainage.
2. Monitor fluid intake and urine output.
3. Check the abdominal wound for redness or swelling.
4. Teach the reason for a prolonged rehabilitation process.

Answer 16

2.

Question 17

Which of the following actions by a nurse who is administering fondaparinux to a client with venous thrombo-embolism (VTE) indicates that more education about the medication is needed?

1. The nurse avoids rubbing the injection site after giving the medication.
2. The nurse injects the medication into the abdominal subcutaneous tissue.
3. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication.
4. The nurse ejects the air bubble in the syringe before administering the medication.

Answer 17

4.

Question 18

While working in the outpatient clinic, the nurse notes that the medical record states that a client has intermittent claudication. Which of the following client statements is consistent with this information?

1. “When I stand too long, my feet start to swell up.”
2. “Sometimes I get tired when I climb a lot of stairs.”
3. “My fingers hurt when I go outside in cold weather.”
4. “My legs cramp whenever I walk more than a block.”

Answer 18

4.

Question 19

The nurse is developing a teaching plan for a client newly diagnosed with peripheral artery disease (PAD). Which of the following information should the nurse include?

1. “Exercise only if you do not experience any pain.”
2. “It is very important that you stop smoking cigarettes.”
3. “Try to keep your legs elevated whenever you are sitting.”
4. “Put on support hose early in the day before swelling occurs.”

Answer 19

2.

Question 20

The nurse is admitting a client to the emergency department with a history of an abdominal aortic aneurysm with severe back pain and absent pedal pulses. Which of the following actions should the nurse take first?

1. Obtain the blood pressure.
2. Ask the client about tobacco use.
3. Draw blood for ordered laboratory testing.
4. Assess for the presence of an abdominal bruit.

Answer 20

1.

Question 21

Which of the following clients admitted to the emergency department should the nurse assess first?

1. 62-year-old who has gangrenous ulcers on both feet
2. 50-year-old who is complaining of “tearing” chest pain
3. 45-year-old who is taking anticoagulants and has bloody stools
4. 36-year-old who has right calf tenderness, redness, and swelling

Answer 21

2.

Question 22

Immediately after repair of an abdominal aortic aneurysm, a client has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which of the following actions should the nurse take first?

1. Wrap both the legs in warm blankets.
2. Notify the surgeon and anaesthesiologist.
3. Document that the pulses are absent and recheck in 30 minutes.
4. Review the preoperative assessment form for data about the pulses.

Answer 22

4.

Question 23

The nurse is caring for a client on the first postoperative day after an abdominal aortic aneurysm repair. Which of the following assessment findings is most important to communicate to the health care provider?

1. Absence of flatus
2. Loose, bloody stools
3. Hypotonic bowel sounds
4. Abdominal pain with palpation

Answer 23

2.

Question 24

A client asks the nurse if there are any natural products that would decrease anticoagulant effects. The nurse tells the client that which of the following natural products causes a decrease in anticoagulant effects?

1. Horse chestnut
2. Licorice root
3. Turmeric
4. Green tea

Answer 24

4.

Question 25

The nurse is caring for a client with peripheral artery disease who is Aspirin intolerant. Which of the following medications should the nurse anticipate the health care provider prescribing for the client related to this intolerance? 1. Pentoxifylline 2. Clopidogrel 3. Ramipril 4. Warfarin

Answer 25

2.

Question 26

The nurse is planning expected outcomes for a client with thromboangiitis obliterans (Buerger’s disease). Which of the following outcomes has the highest priority for this client? 1. Cessation of smoking 2. Control of serum lipid levels 3. Maintenance of appropriate weight 4. Demonstration of meticulous foot care

Answer 26

1.

Question 27

The nurse is caring for a client with a right calf venous thrombo-embolism. Which of the following information requires immediate action by the nurse? 1. Complaint of left calf pain 2. New onset shortness of breath 3. Red skin colour of left lower leg 4. Temperature of 38°C (100.4°F)

Answer 27

2.

Question 28

Which of the following responses by a client that is on anticoagulant therapy indicates the need for further teaching? 1. “I can still have a glass of wine with my dinner” 2. “For pain relief I will take ibuprofen” 3. “I take my pills at two o’clock every day” 4. “I will use an electric razor for shaving”

Answer 28

2.

Question 29

The nurse is admitting a client with acute cholecystitis. Which of the following findings is most important for the nurse to report to the health care provider? 1. The client’s urine is bright yellow. 2. The client’s stools are clay coloured. 3. The client complains of chronic heartburn. 4. The client has an increase in pain after eating.

Answer 29

2.

Question 30

The nurse is caring for a client following an incisional cholecystectomy for cholelithiasis. Which of the following actions is priority for the nurse to implement? 1. Client education about low-fat food choices 2. Perform leg exercises hourly while awake. 3. Ambulate the evening of the operative day. 4. Turn, cough, and deep breathe every 2 hours.

Answer 30

4.

Question 31

The nurse is admitting a client with increasing abdominal pain who is diagnosed with an ectopic pregnancy. The client begins to cry and asks the nurse to leave her alone to grieve. Which of the following actions should the nurse take next? 1. Stay with the client and encourage her to discuss her feelings. 2. Explain the reason for taking vital signs every 15–30 minutes. 3. Close the door to the client’s room and minimize disturbances.

Answer 31

2.

Question 32

The nurse has just received change-of-shift report about the following four clients. Which of the following clients should be assessed first? 1. A client with a possible ectopic pregnancy who is complaining of severe shoulder pain 2. A client in the fifteenth week of gestation who is experiencing uterine cramping and spotting 3. A client who has a radium implant in place to treat cervical cancer and is crying in her room 4. A client with ovarian cancer who is complaining of 5/10 pain after an abdominal hysterectomy

Answer 32

1.

Question 33

Family members ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring for a client. Which of the following responses by the nurse is best? 1. “This type of monitoring system is complex and highly skilled staff are needed.” 2. “The monitoring system helps show whether blood flow to the brain is adequate.” 3. “The ventriculostomy monitoring system helps check for alterations in cerebral perfusion pressure.” 4. “This monitoring system has multiple benefits including facilitation of cerebro-spinal fluid drainage.”

Answer 33

2.

Question 34

The nurse is caring for a client with a head injury and has admission vital signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse? 1. Blood pressure 156/60, pulse 55, respirations 12 2. Blood pressure 130/72, pulse 90, respirations 32 3. Blood pressure 148/78, pulse 112, respirations 28 4. Blood pressure 110/70, pulse 120, respirations 30

Answer 34

1.

Question 35

The nurse is assessing a client who is unconscious and applies a painful stimulus to the nail beds. The client responds with internal rotation, adduction, and flexion of the arms. Which of the following terms should the nurse use when documenting the findings? 1. Flexion withdrawal 2. Localization of pain 3. Decorticate posturing 4. Decerebrate posturing

Answer 35

3.

Question 36

Which of the following parameters is best for the nurse to monitor to determine whether the prescribed IV mannitol has been effective for an unconscious client? 1. Hematocrit 2. Blood pressure 3. Oxygen saturation 4. Intracranial pressure

Answer 36

4.

Question 37

A client with a head injury opens his or her eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. Which of the following Glasgow Coma Scale scores should the nurse document? 1. 9 2. 11 3. 13 4. 15

Answer 37

2.

Question 38

The nurse is admitting a client to the emergency department (ED) who is unconscious following a head injury. The client’s spouse and children stay at the client’s side and constantly ask about the treatment being given. What of the following actions is best for the nurse to take? 1. Ask the family to stay in the waiting room until the initial assessment is completed. 2. Allow the family to stay with the client and briefly explain all procedures to them. 3. Call the family’s pastor or spiritual advisor to support them while initial care is given. 4. Refer the family members to the hospital counselling service to deal with their anxiety.

Answer 38

2.

Question 39

A client who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should be included in the plan of care? 1. Keep the head of the bed elevated to 30 degrees. 2. Position the client with the knees and hips flexed. 3. Encourage coughing and deep breathing to improve oxygenation. 4. Cluster nursing interventions to provide uninterrupted rest periods.

Answer 39

1.

Question 40

The nurse is caring for a client with a head injury who has clear nasal drainage. Which of the following actions should the nurse take? 1. Have the client blow the nose. 2. Check the nasal drainage for glucose. 3. Assure the client that rhinorrhea is normal after a head injury. 4. Obtain a specimen of the fluid to send for culture and sensitivity.

Answer 40

2.

Question 41

The nurse is caring for a client who has a head injury and is diagnosed with a concussion. Which of the following actions should the nurse plan to take? 1. Coordinate the transfer of the client to the operating room. 2. Provide discharge instructions about monitoring neurological status. 3. Transport the client to radiology for magnetic resonance imaging (MRI) of the brain. 4. Arrange to admit the client to the neurological unit for observation for 24 hours.

Answer 41

2.

Question 42

A client who is suspected of having an epidural hematoma is admitted to the emergency department. Which of the following actions should the nurse plan to take? 1. Administer IV furosemide. 2. Initiate high-dose barbiturate therapy. 3. Type and crossmatch for blood transfusion. 4. Prepare the client for immediate craniotomy.

Answer 42

4.

Question 43

The nurse is admitting a client with a basal skull fracture and notes clear drainage from the client’s nose. Which of these admission orders should the nurse’s question? 1. Insert nasogastric tube. 2. Turn client every 2 hours. 3. Keep the head of bed elevated. 4. Apply cold packs for facial bruising.

Answer 43

1.

Question 44

Which of the following assessment information should the nurse collect to determine whether a client is developing post-concussion syndrome? 1. Muscle resistance 2. Short-term memory 3. Glasgow coma scale 4. Pupil reaction to light

Answer 44

2.

Question 45

The nurse is admitting a client who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe? 1. Judgement changes 2. Expressive aphasia 3. Right-sided weakness 4. Difficulty swallowing

Answer 45

1.

Question 46

Which of the following statements by a client who is being discharged from the emergency department (ED) after a head injury indicates a need for intervention by the nurse? 1. “I will return if I feel dizzy or nauseated.” 2. “I am going to drive home and go to bed.” 3. “I do not even remember being in an accident.” 4. “I can take acetaminophen for my headache.”

Answer 46

2.

Question 47

The nurse is caring for a client following a craniectomy and left anterior fossae incision who has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weakness. Which of the following is an appropriate nursing intervention? 1. Position the bed flat and log roll the client. 2. Cluster nursing activities to allow longer rest periods. 3. Turn and reposition the client side to side every 2 hours. 4. Perform range-of-motion (ROM) exercises every 4 hours.

Answer 47

4.

Question 48

The nurse is caring for a client who has increased intracranial pressure and is disoriented and anxious. Which of the following nursing actions should be included in the plan of care? 1. Encourage family members to remain at the bedside. 2. Apply soft restraints to protect the client from injury. 3. Keep the room well lighted to improve client orientation. 4. Minimize contact with the client to decrease sensory input.

Answer 48

1.

Question 49

take out

Answer 49

3.

Question 50

take out

Answer 50

3.

Question 51

The nurse is assessing a client with bacterial meningitis and obtains the following data. Which of the following findings should be reported immediately to the health care provider? 1. The client has a positive Kernig’s sign. 2. The client complains of having a stiff neck. 3. The client’s temperature is 38.3°C (100.9°F). 4. The client’s blood pressure is 86/42 mm Hg.

Answer 51

4.

Question 52

The nurse is caring for a client who has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first? 1. Elevate the head of the client’s bed to 60 degrees. 2. Document the BP and ICP in the client’s record. 3. Report the BP and ICP to the health care provider. 4. Continue to monitor the client’s vital signs and ICP.

Answer 52

3.

Question 53

The nurse is suctioning a client with a traumatic head injury and notes that the intracranial pressure has increased from 14 to 16 mm Hg. Which of the following actions should the nurse take first? 1. Document the increase in intracranial pressure. 2. Assure that the client’s neck is not in a flexed position. 3. Notify the health care provider about the change in pressure. 4. Increase the rate of the prescribed propofol infusion.

Answer 53

2.

Question 54

After receiving change of shift report, which of the following clients should the nurse assess first? 1. A 44-year-old receiving IV antibiotics for meningococcal meningitis 2. A 23-year-old who had a skull fracture and craniotomy the previous day 3. A 30-year-old who has an intracranial pressure (ICP) monitor in place after a head injury a week ago 4. A 61-year-old who has increased ICP and is receiving hyperventilation therapy

Answer 54

4.

Question 55

The nurse is caring for a client with possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first? 1. Draw blood for arterial blood gases (ABGs). 2. Administer 5% hypertonic saline intravenously. 3. Administer acetaminophen 650 mg orally. 4. Send client for computed tomography (CT) of the head.

Answer 55

2.

Question 56

After the emergency department nurse has received a status report on the following clients who have been admitted with head injuries, which client should the nurse assess first? 1. A client whose cranial radiograph shows a linear skull fracture 2. A client who has an initial Glasgow Coma Scale score of 13 3. A client who lost consciousness for a few seconds after a fall 4. A client whose right pupil is 10 mm and unresponsive to light

Answer 56

4.

Question 57

Which of the following assessment findings in a client who was admitted the previous day with a basilar skull fracture is most important to report to the health care provider? 1. Bruising under both eyes 2. Complaint of severe headache 3. Large ecchymosis behind one ear 4. Temperature of 38.6°C (101.5°F)

Answer 57

4.

Question 58

The nurse is monitoring a client’s intracranial pressure (ICP) with an intraventricular catheter. Which of the following information obtained by the nurse is most important to communicate to the health care provider? 1. Oral temperature 38.7°C (101.7°F) 2. Apical pulse 102 beats/minute 3. Intracranial pressure 15 mm Hg 4. Mean arterial pressure 90 mm Hg

Answer 58

1.

Question 59

The charge nurse observes an inexperienced staff nurse who is caring for a client who has had a craniotomy for a brain tumour. Which of the following actions by the inexperienced nurse requires the charge nurse to intervene? 1. The staff nurse suctions the client every 2 hours. 2. The staff nurse assesses neurologic status every hour. 3. The staff nurse elevates the head of the bed to 30 degrees. 4. The staff nurse administers a mild analgesic before turning the client.

Answer 59

1.

Question 60

A client is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor by the partner. Which of the following actions should the nurse take first? 1. Obtain oxygen saturation. 2. Check pupil reaction to light. 3. Palpate the head for hematoma. 4. Assess Glasgow Coma Scale (GCS).

Answer 60

1.

Question 61

Which of the following assessment findings should the nurse report immediately to the health care provider when caring for a client with increased intracranial pressure? 1. CPP38mmHg 2. MAP92mmHg 3. PaO2 110 mm Hg 4. BP 140/82

Answer 61

1.

Question 62

Which of the following information about a client who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? 1. Intracranial pressure of 15 mm Hg 2. Cerebro-spinal fluid (CSF) drainage of 15 mL/hour 3. Pressure of oxygen in brain tissue (PbtO2) is 14 mm Hg 4. Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/minute

Answer 62

3.

Question 63

The nurse is caring for a client who has had a head injury. Which of the following assessment information requires the most rapid action by the nurse? 1. The client is more difficult to arouse. 2. The client’s pulse is slightly irregular. 3. The client’s blood pressure increases from 120/54 to 136/62 mm Hg. 4. The client indicates a headache at pain level 5 of a 10-point scale.

Answer 63

1.

Question 64

The nurse is caring for a client with a head injury. Which of the following findings should be reported rapidly to the health care provider? 1. Urine output of 800 mL in the last hour 2. Intracranial pressure of 16 mm Hg when client is turned 3. Ventriculostomy drains 10 mL of cerebro-spinal fluid per hour 4. LICOX brain tissue oxygenation catheter shows PbtO2 of 38 mm Hg.

Answer 64

1.

Question 65

The nurse is providing discharge teaching with a client who has a concussion. Which of the following time frames should the nurse tell the client to continue to monitor for post-concussion syndrome? 1. Up to 2 weeks 2. Up to 4 weeks 3. Up to 2 months 4. Up to 6 months

Answer 65

3.

Question 66

take out

Answer 66

3.

Question 67

The nurse is caring for a client with increased intracranial pressure (IICP). Which of the following are late signs of IICP? (Select all that apply.) 1. Unilateral hemiparesis 2. Papilledema 3. Decorticate posturing 4. Decerebrate posturing 5. Hyperthermia

Answer 67

3,4,5

Question 68

The nurse is caring for a client who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects. Which of the following actions should the nurse anticipate as treatment for this client? 1. Prophylactic clipping of cerebral aneurysms 2. Heparin via continuous intravenous infusion 3. Oral administration of low dose Aspirin therapy 4. Therapy with tissue plasminogen activator (tPA)

Answer 68

3.

Question 69

The nurse is caring for a client who has recently had a stroke. When reviewing the clients’ laboratory report, which of the following results should the nurse report the health care provider? 1. PaCO2 51 mm Hg 2. pH 7.41 3. PaO2 96 mm Hg 4. WBC 9.2 ́ 109/L

Answer 69

1.

Question 70

The nurse is admitting a client who had a stroke and is experiencing right-sided arm and leg paralysis and facial drooping on the right side. Which of the following clinical manifestations should the nurse expect to find? 1. Impulsive behaviour 2. Right-sided neglect 3. Hyperactive left-sided reflexes 4. Difficulty in understanding commands

Answer 70

4.

Question 71

The nurse receives a verbal report that a client has an occlusion of the left posterior cerebral artery. Which of the following findings should the nurse anticipate? 1. Dysphasia 2. Confusion 3. Visual deficits 4. Poor judgement

Answer 71

3.

Question 72

The health care provider prescribes clopidogrel for a client with cerebral atherosclerosis. Which of the following information should the nurse include when teaching the client about the new medication? 1. Monitor and record the blood pressure daily. 2. Call the health care provider if stools are tarry. 3. It will dissolve clots in the cerebral arteries. 4. It will reduce cerebral artery plaque formation.

Answer 72

2.

Question 73

The health care provider recommends a carotid endarterectomy for a client with carotid atherosclerosis and a history of transient ischemic attacks (TIAs). The client asks the nurse to describe the procedure. Which of the following responses by the nurse is appropriate? 1. “The carotid endarterectomy involves surgical removal of plaque from an artery in the neck.” 2. “The diseased portion of the artery in the brain is removed and replaced with a synthetic graft.” 3. “A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed.” 4. “A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque.”

Answer 73

1.

Question 74

The nurse is assessing a client with a possible stroke and finds that the client’s aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these prescriptions by the health care provider should the nurse question? 1. Infuse normal saline at 75 mL/hour. 2. Keep head of bed elevated at least 30 degrees. 3. Administer tissue plasminogen activator (tPA) per protocol. 4. Titrate labetalol drip to keep BP less than 140/90 mm Hg.

Answer 74

4.

Question 75

A client with a history of several transient ischemic attacks (TIAs) arrives in the emergency department with hemiparesis and dysarthria that started 2 hours previously. Which of the following procedures should the nurse anticipate? 1. Surgical endarterectomy 2. Transluminal angioplasty 3. Intravenous heparin administration 4. Tissue plasminogen activator (tPA) infusion

Answer 75

4.

Question 76

The nurse identifies the nursing diagnosis of impaired verbal communication for a client with expressive aphasia. Which of the following actions should the nurse implement to help the client communicate? 1. Have the client practice facial and tongue exercises. 2. Ask simple questions that the client can answer with “yes” or “no.” 3. Develop a list of words that the client can read and practice reciting. 4. Prevent embarrassing the client by changing the subject if the client does not respond

Answer 76

2.

Question 77

The nurse is caring for a client who had a stroke affecting the right hemisphere of the brain. Which of the following nursing diagnoses is appropriate based on knowledge of the effects of right brain damage? 1. Impaired physical mobility related to decrease in muscle control (right hemiplegia). 2. Risk for injury as evidenced by alteration in cognitive functioning 3. Impaired verbal communication related to environmental barrier (impaired speech) 4. Ineffective coping related to insufficient sense of control (depression and distress about disability).

Answer 77

2.

Question 78

The nurse is admitting a client with left-sided homonymous hemianopsia resulting from a stroke. Which of the following interventions should the nurse include in the plan of care during the acute period of the stroke? 1. Apply an eye patch to the left eye. 2. Approach the client from the left side. 3. Place objects needed for activities of daily living on the client’s right side. 4. Reassure the client that the visual deficit will resolve as the stroke progresses.

Answer 78

3.

Question 79

The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to insufficient dietary intake (secondary to impaired self-feeding ability) for a client with right-sided hemiplegia. Which of the following interventions should be included in the plan of care? 1. Provide a wide variety of food choices. 2. Provide oral care before and after meals. 3. Assist the client to eat with the left hand. 4. Teach the client the “chin-tuck” technique.

Answer 79

3.

Question 80

The nurse is caring for a client who had a stroke resulting from a ruptured aneurysm and subarachnoid hemorrhage. Which of the following interventions should be included in the care plan? 1. Applying compression gradient stockings 2. Assisting to dangle on edge of bed and assess for dizziness 3. Encouraging client to cough and deep breathe every 4 hours 4. Inserting an oropharyngeal airway to prevent airway obstruction

Answer 80

1.

Question 81

The nurse is caring for a client who has had a stroke and has a new prescription to attempt oral feedings. After assessing the client’s gag reflex, which of the following actions should the nurse do next? 1. Order a varied puréed diet. 2. Assess the client’s appetite. 3. Assist the client into a chair. 4. Offer the client a sip of juice.

Answer 81

3.

Question 82

The nurse is caring for a client who has right-sided weakness after a stroke and is attempting to use the left hand for feeding and other activities. The client’s partner insists on feeding and dressing him, telling the nurse, “I just don’t like to see him struggle.” Which of the following nursing diagnoses is most appropriate for the client? 1. Situational low self-esteem related to pattern of helplessness 2. Interrupted family processes related to shift in family roles (effects of illness of a family member) 3. Disabled family coping related to differing coping styles between support person and client 4. Impaired nutrition: less than body requirements related to insufficient dietary intake (hemiplegia and aphasia)

Answer 82

3.

Question 83

take out

Answer 83

2.

Question 84

A client is admitted to the hospital with dysphasia and right-sided weakness that resolves in a few hours. The nurse will anticipate teaching the client about 1. Alteplase (tPA). 2. Aspirin. 3. Warfarin. 4. Nimodipine.

Answer 84

2.

Question 85

The nurse is caring for a client with a left-sided brain stroke who suddenly bursts into tears when family members visit. Which of the following actions should the nurse implement? 1. Use a calm voice to ask the client to stop the crying behaviour. 2. Explain to the family that depression is normal following a stroke. 3. Have the family members leave the client alone for a few minutes. 4. Teach the family that emotional outbursts are common after strokes.

Answer 85

4.

Question 86

The nurse obtains all of the following information about a client in the clinic. When developing a plan to decrease stroke risk, which of the following risk factors is most important for the nurse to address? 1. The client has a daily glass of wine to relax. 2. The client is 13 kg above the ideal weight. 3. The client works at a desk and relaxes by watching television. 4. The client’s blood pressure is usually about 180/90 mm Hg.

Answer 86

4.

Question 87

The nurse is caring for a client with sudden-onset right-sided weakness who has a CT scan and is diagnosed with an intracerebral hemorrhage. Which of the following information about the client is most important to communicate to the health care provider? 1. The client’s speech is difficult to understand. 2. The client’s blood pressure is 144/90 mm Hg. 3. The client takes a diuretic because of a history of hypertension. 4. The client has atrial fibrillation and takes warfarin.

Answer 87

4.

Question 88

The nurse is admitting a client with right-sided weakness that started 90 minutes earlier to the emergency department and all these diagnostic tests are prescribed. Which of the following tests should be done first? 1. Electrocardiogram (ECG) 2. Complete blood count (CBC) 3. Chest radiograph (chest x-ray) 4. Noncontrast computed tomography (CT) scan

Answer 88

4.

Question 89

The nurse is caring for a client with a stroke who has progressive development of neurological deficits with increasing weakness and decreased level of consciousness (LOC). Which of the following nursing diagnoses has the highest priority for the client? 1. Impaired physical mobility related to decrease in muscle strength 2. Risk for injury as evidenced by alteration in cognitive function 3. Risk for impaired skin integrity as evidenced by pressure over bony prominence (immobilty) 4. Risk for aspiration as evidenced by impaired ability to swallow

Answer 89

4.

Question 90

The nurse is caring for a client who has had a subarachnoid hemorrhage and is being cared for in the intensive care unit. Which of the following information about vasospasms should the nurse be aware of when planning care? 1. The client’s blood pressure is 100/50 mm Hg. 2. Endothelin will subside the vasospasm 3. The cerebro-spinal fluid (CSF) report shows red blood cells (RBCs). 4. Peak time for occurrence is 7–10 days post bleed.

Answer 90

4.

Question 91

The nurse is teaching a client’s family about immediate stroke care. Which of the following information should the nurse include in teaching plan? 1. Hypotension post stroke is normal. 2. Antihypertensive medication is administered if the mean arterial pressure is >130 mm Hg. 3. Diuretic ordered in the systolic BP is >160 mm Hg. 4. Withholding medications until the degree of dysphasia is known.

Answer 91

2.

Question 92

The nurse is receiving a change-of-shift report. Which of the following clients should the nurse see first? 1. A client with right-sided weakness who has an infusion of tPA prescribed 2. A client who has atrial fibrillation and a new prescription for warfarin 3. A client who experienced a transient ischemic attack yesterday who has a dose of Aspirin due 4. A client with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled

Answer 92

1.

Question 93

The nurse is caring for a client who had a stroke and is in the acute phase of care. Which of the following systems is priority? 1. Neurological system 2. Respiratory system 3. Gastro-intestinal system 4. Genito-urinary system

Answer 93

2.

Question 94

The nurse is admitting a client with left-sided hemiparesis who has arrived by ambulance to the emergency department. Which of the following actions should the nurse take first? 1. Check the respiratory rate. 2. Monitor the blood pressure. 3. Send the client for a CT scan. 4. Obtain the Glasgow Coma Scale score.

Answer 94

1.

Question 95

The nurse is admitting a client who began experiencing right-sided arm and leg weakness to the emergency department. In which order should the nurse implement these actions included in the stroke protocol? (Select all that apply.) a. Obtain CT scan without contrast. b. Infuse tissue plasminogen activator (tPA). c. Administer oxygen to keep O2 saturation >95%. d. Use National Institute of Health Stroke Scale to assess client.

Answer 95

cdab

Question 96

The nurse is counselling a client about ways to prevent fractures. Which of the following information should the nurse include? 1. Tack down throw rugs in the home. 2. Most falls happen outside the home. 3. Buy shoes that provide good support and are comfortable to wear. 4. Range-of-motion exercises should be taught by a physical therapist.

Answer 96

3.

Question 97

The nurse is caring for a client who has a cast in place after fracturing the radius and the client asks when the cast can be removed. Which of the following information related to the length of time that the cast will need to remain in place should the nurse tell the client? 1. Several months 2. At least 3 weeks 3. Until swelling of the wrist has resolved 4. Until x-rays show complete bony union

Answer 97

2.

Question 98

The nurse is caring for a client who has a comminuted fracture of the right femur and has Buck’s traction in place while waiting for surgery. Which of the following actions should the nurse implement to assess for pressure areas on the client’s back and sacral area and to provide skin care? 1. Loosen the traction and have the client turn onto the unaffected side. 2. Place a pillow between the client’s legs and turn gently to each side. 3. Turn the client partially to each side with the assistance of another nurse. 4. Have the client lift the buttocks by bending and pushing with the left leg.

Answer 98

4.

Question 99

The nurse is caring for a client with a left femur fracture who has a hip spica cast applied. Which of the following nursing interventions should be included in the plan of care? 1. Avoid placing the client in the prone position. 2. Use the cast support bar to reposition the client. 3. Ask the client about any abdominal discomfort or nausea. 4. Discuss the reasons for remaining on bed rest for several weeks.

Answer 99

3.

Question 100

The nurse is caring for a client who has a long-arm plaster cast applied for immobilization of a fractured left radius. Which of the following actions should the nurse implement until the cast has completely dried? 1. Keep the left arm in a dependent position. 2. Handle the cast with the palms of the hands. 3. Place gauze around the cast edge to pad any roughness. 4. Cover the cast with a small blanket to absorb the dampness.

Answer 100

2.

Question 101

The nurse is providing discharge teaching to a client who has a short-arm plaster cast applied. Which of the following client statements indicates a good understanding of the discharge teaching? 1. “I can get the cast wet as long as I dry it right away with a hair dryer.” 2. “I should avoid moving my fingers and elbow until the cast is removed.” 3. “I will apply an ice pack to the cast over the fracture site for the next 24 hours.” 4. “I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.”

Answer 101

3.

Question 102

The nurse is caring for a client who has had an open reduction and internal fixation (ORIF) of left lower leg fractures who indicates constant severe pain in the leg which is unrelieved by the prescribed morphine. Pulses are faintly palpable and the foot is cool. Which of the following actions should the nurse take next? 1. Notify the health care provider. 2. Assess the incision for redness. 3. Reposition the left leg on pillows. 4. Check the client’s blood pressure.

Answer 102

1.

Question 103

The nurse is caring for a client who is on bed rest after having a complex pelvic fracture. Which of the following assessment findings is most important to report to the health care provider? 1. The client states that the pelvis feels unstable. 2. Abdominal distention is present and bowel tones are absent. 3. There are ecchymoses on the abdomen and hips. 4. The client complains of pelvic pain with palpation.

Answer 103

2.

Question 104

The nurse is caring for a client with Buck’s traction who had an intracapsular fracture of the left femur. Which of the following actions should the nurse take in order to evaluate the effectiveness of Buck’s traction? 1. Assess for hip contractures. 2. Monitor for hip dislocation. 3. Check the peripheral pulses. 4. Ask about left hip pain level.

Answer 104

4.

Question 105

The nurse is preparing a client with lower leg fracture and an external fixation device in place for discharge. Which of the following information should the nurse include in the discharge teaching? 1. “You will need to assess and clean the pin insertion sites daily.” 2. “The external fixator can be removed during the bath or shower.” 3. “You will need to remain on bed rest until bone healing is complete.” 4. “Prophylactic antibiotics are used until the external fixator is removed.”

Answer 105

1.

Question 106

The nurse is preparing to assist a client who has had an open reduction and internal fixation (ORIF) of a hip fracture out of bed for the first time. Which of the following actions should the nurse take first? 1. Use a mechanical lift to transfer the client from the bed to the chair. 2. Check the postoperative orders for the client’s weight-bearing status. 3. Avoid administration of pain medications before getting the client up. 4. Delegate the transfer of the client out of bed to an unregulated care provider (UCP).

Answer 106

2.

Question 107

The nurse is planning discharge teaching for a client who has had a repair of a fractured mandible. Which of the following information should the nurse will include in the teaching plan? 1. When and how to cut the immobilizing wires 2. Self-administration of nasogastric tube feedings 3. The use of sterile technique for dressing changes 4. The importance of including high-fibre foods in the diet

Answer 107

1.

Question 108

After the health care provider has recommended an amputation for a client who has ischemic foot ulcers, the client tells the nurse, “If they want to cut off my foot, they should just shoot me instead.” Which of the following responses by the nurse is best? 1. “Many people are able to function normally with a foot prosthesis.” 2. “I understand that you are upset, but you may lose the foot anyway.” 3. “Tell me what you know about what your options for treatment are.” 4. “If you do not want the surgery, you do not have to have an amputation.”

Answer 108

3.

Question 109

The nurse is caring for a client who is 1 day postoperative below-the-knee amputation who indicates pain in the amputated limb. Which of the following actions is best for the nurse to take? 1. Explain the reasons for the phantom limb pain. 2. Administer prescribed analgesics to relieve the pain. 3. Loosen the compression bandage to decrease incisional pressure. 4. Remind the client that this phantom pain will diminish over time.

Answer 109

2.

Question 110

The nurse is preparing a client who had an above-the-knee amputation for discharge. Which of the following client statements indicates that the nurse’s discharge teaching has been effective? 1. “I should lay on my abdomen for 30 minutes three or four times a day.” 2. “I should elevate my residual limb on a pillow two or three times a day.” 3. “I should change the limb sock when it becomes soiled or stretched out.” 4. “I should use lotion on the stump to prevent drying and cracking of the skin.”

Answer 110

1.

Question 111

The nurse is preparing a client for discharge 4 days after insertion of a femoral head prosthesis using a posterior approach. Which of the following client statements indicates a need for additional discharge instructions? 1. “I should not cross my legs while sitting.” 2. “I will use a toilet elevator on the toilet seat.” 3. “I will have someone else put on my shoes and socks.” 4. “I can sleep in any position that is comfortable for me.”

Answer 111

4.

Question 112

Which of the following nursing actions should the nurse include in the plan of care for a client who has had a total knee arthroplasty? 1. Avoid extension of the knee beyond 120 degrees. 2. Use a compression bandage to keep the knee flexed. 3. Start progressive knee exercises to obtain 90-degree flexion. 4. Teach about the need to avoid weight bearing for 4 weeks.

Answer 112

3.

Question 113

The nurse is caring for a client with ulnar drift caused by rheumatoid arthritis (RA) who is scheduled for an arthroplasty of the hand. Which of the following client statements indicates realistic expectation for the surgery? 1. “I will be able to use my fingers to grasp objects better.” 2. “I will not have to do as many hand exercises after the surgery.” 3. “This procedure will prevent further deformity in my hands and fingers.” 4. “My fingers will appear more normal in size and shape after this surgery.”

Answer 113

1.

Question 114

The nurse is providing home care instructions to a client who has multiple forearm fractures and a long-arm cast on the right arm. Which of the following information should the nurse include in the teaching plan? 1. Keep the hand immobile to prevent soft tissue swelling. 2. Keep the right shoulder elevated on a pillow or cushion. 3. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for the first 48 hours after the injury. 4. Call the health care provider for increased swelling or numbness.

Answer 114

4.

Question 115

The nurse is admitting a client who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast and has a sling. Which of the following nursing interventions will be included in the plan of care? 1. Use surgical net dressing to hang the arm from an IV pole. 2. Immobilize the fingers on the left hand with gauze dressings. 3. Assess the left axilla and change absorbent dressings as needed. 4. Assist the client in passive range of motion (ROM) for the right arm.

Answer 115

3.

Question 116

The nurse is caring for a client who had hip replacement surgery using the posterior approach. Which of the following client actions requires rapid intervention by the nurse? 1. The client uses crutches with a swing-to gait. 2. The client leans over to pull shoes and socks on. 3. The client sits straight up on the edge of the bed. 4. The client bends over the sink while brushing the teeth.

Answer 116

2.

Question 117

The nurse is caring for a client who has been hospitalized for 3 days with a hip fracture who has sudden onset shortness of breath and tachypnea. The client tells the nurse, “I feel like I am going to die!” Which of the following actions should the nurse take first? 1. Stay with the client and offer reassurance. 2. Administer the prescribed PRN oxygen at 4 L/minute. 3. Check the client’s legs for swelling or tenderness. 4. Notify the health care provider about the symptoms.

Answer 117

2.

Question 118

The nurse is admitting a client to the emergency department after falling on the right arm and shoulder. Which of the following findings is most important for the nurse to communicate to the health care provider immediately? 1. There is bruising at the shoulder area. 2. The right arm appears shorter than the left. 3. There is decreased range of motion of the shoulder. 4. The client is complaining of arm and shoulder pain.

Answer 118

2.

Question 119

The nurse is caring for a client who arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. Which of the following prescribed collaborative interventions will the nurse implement first? 1. Wrap the ankle and apply an ice pack. 2. Administer naproxen 500 mg PO. 3. Give acetaminophen with codeine. 4. Take the client to the radiology department for x-rays.

Answer 119

1.

Question 120

The nurse is caring for a client in the emergency department who has a soft tissue injury and an open leg fracture. Which of the following actions should the nurse implement first? 1. If dislocation, apply compression bandage. 2. Realignment of the bone(s) 3. Administer tetanus with an open fracture. 4. Apply heat to the affected area.

Answer 120

3.

Question 121

The nurse is caring for a client in the emergency department who is experiencing severe pain and is diagnosed with a patellar dislocation. Which of the following actions should the nurse implement first? 1. Applying a knee immobilizer 2. Implementing passive knee flexion 3. Limiting activity restrictions 4. Preparing the client for conscious sedation

Answer 121

4.

Question 122

The nurse is caring for a client in the emergency department following a motor vehicle accident who has massive right lower leg swelling. Which of the following actions will the nurse take first? 1. Elevate the leg on pillows. 2. Apply a compression bandage. 3. Check leg pulses and sensation. 4. Place ice packs on the lower leg.

Answer 122

3.

Question 123

The nurse is caring for a client in the emergency department who has possible left lower leg fractures. Which of the following actions should the nurse implement initially? 1. Elevate the left leg. 2. Splint the lower leg. 3. Obtain information about the tetanus immunization status. 4. Check the popliteal, dorsalis pedis, and posterior tibial pulses.

Answer 123

4.

Question 124

The nurse is developing a care plan for a client with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia. Which of the following nursing diagnoses is priority? 1. Activity intolerance related to physical deconditioning 2. Risk for constipation as evidenced by electrolyte imbalance 3. Risk for impaired skin integrity as evidenced by pressure over bony prominence 4. Risk for infection as evidenced by invasive procedure

Answer 124

4.

Question 125

The nurse is caring for a client with a fractured pelvis and on day 2 of the hospitalization the client develops acute onset confusion. Which of the following actions should the nurse take first? 1. Take the blood pressure. 2. Assess client orientation. 3. Check pupil reaction to light. 4. Assess the oxygen saturation.

Answer 125

4.

Question 126

Which of the following information obtained by the emergency department nurse when admitting a client with a left femur fracture is most important to report to the health care provider? 1. Bruising of the left thigh 2. Complaints of left thigh pain 3. Outward pointing toes on the left foot 4. Prolonged capillary refill of the left foot

Answer 126

4.

Question 127

The nurse is caring for a client who has just arrived on the orthopedic unit after a right above-the-knee amputation with an immediate prosthetic fitting. Which of the following actions should the nurse implement first? 1. Place the client in a prone position. 2. Check the surgical site for hemorrhage. 3. Remove the prosthesis and wrap the site. 4. Keep the residual leg elevated on a pillow.

Answer 127

2.

Question 128

Before assisting a client with ambulation on the day after a total hip replacement, which of the following actions is most important for the nurse to implement? 1. Administer the ordered oral opioid pain medication. 2. Instruct the client about the benefits of ambulation. 3. Ensure that the incisional drain has been discontinued. 4. Change the hip dressing and document the wound appearance

Answer 128

1.

Question 129

The nurse is providing discharge teaching to a client with a sprained right ankle. Which of the following information should be included in the teaching plan? (Select all that apply.) 1. Elevate the limb. 2. Use nonsteroidal anti-inflammatory drugs as required. 3. Apply warm moist heat for 45 minutes, three times per day. 4. Use an elastic bandage on the ankle during activity 5. Use ice alternating with heat 48 hours after the injury.

Answer 129

1,2,4.

Question 130

In which order will the nurse take these actions when caring for a client with left leg fractures after a motor vehicle accident? a. Obtain x-rays. b. Check pedal pulses. c. Assess lung sounds. d. Take blood pressure. e. Apply splint to the leg. f. Administer tetanus prophylaxis

Answer 130

c,d,b,e,a,f